Ornament

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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Ornament

AROM (Artificial Rupture of Membranes)

Why women shouldn't fear home birth
by Mayim Bialik, Ph.D.
This short essay is humorous, honest, insightful and inspiring.

See also:

Subsections on this page:




General Safety of AROM



When is it Safe to Rupture Membranes?


Amniotomy - Excellent Patient Education from Kent Midwifery Practice in the UK (Kay Hardie and Virginia Howes)



Variable Decels after AROM



How many times have you seen variables after AROM? I try to make it a practice not to AROM unless absolutely necessary.


One of my ND friends used to AROM at six centimeters. He had been taught that this resulted in shorter labors and less FTP, so he practiced as he had been educated to do.....

We had some L-O-N-G discussions about AROM and shared stories and data and he began to leave the membranes be. His problem-labor rate, lousy-FHT rate, meconium rate, resuscitation rate, and his transport rate have ALL FALLEN since he made this simple change!

An old quote says "The baby is unlikely to get into trouble in labor as long as the membranes are intact".

I agree with you -- don't ROM unless absolutely necessary!



AROM Increases Risk of Infection



I wondered if anybody could help me out with this. I have a copy of the midwife's notes from our birth. Part of the reason we were transferred from home to hospital was because I developed a high fever shortly after AROM at home. The notes say that, between 4am and 10:30 am when we transported, 7 vaginal exams were performed ( 2 after ARM). At least 4 were done at the hospital, on top of those 7. When I protested to the exams (specifically after my membranes were ruptured), both the midwife and OB at the hospital said they were using sterile gloves.

My daughter was hospitalised for "possible sepsis" and I had a diagnosis of "possible chorioamnionitis". What is with all these "possibles"? Can anyone tell me if it sounds like these possible infections could have been caused by the AROM and exams? Amniotic fluid was clear and odorless when membranes were ruptured.


Well, that's nice that they used sterile gloves, but even they know that sterile gloves can still bring germs up from the outside world to your cervix.

The diagnoses of possible sepsis and possible chorioamnionitis may have been made solely on the basis of your high temperature. If the baby was hospitalized for possible sepsis, they almost certainly did a myriad of cultures (usually all orifices and a spinal tap.


About vag. exams and AROM - If they wanted you to get to it, they'd have put it in a much easier place to find.


This is the most profound wisdom I've heard in a long time. Thank you so much. I find myself partly laughing at the humor, but mostly delighted at the simple wisdom.


I figure the reason God/dess gave me such short fingers is so that I wouldn't be tempted to mess with the cervix all the time.


ANTIMICROBIAL PROPERTIES OF AMNIOTIC FLUID AND VERNIX CASEOSA ARE SIMILAR TO THOSE FOUND IN BREAST MILK

Akinbi, H. T., Narendran, V., Pass, A. K., Markart, P., & Hoath, S. B. (2004). Host defense proteins in vernix caseosa and amniotic fluid. American Journal of Obstetrics and Gynecology, 191(6), 2090–2096.

Summary

In this study, researchers analyzed samples of amniotic fluid and vernix caseosa (vernix) from healthy, term gestations to determine the immune properties of these substances. Participants were pregnant women admitted for elective cesarean section after 37 weeks gestation with no prior labor and no signs of chorioamnionitis (intrauterine infection). Women with a history of prenatal fever or premature rupture of membranes, or who received steroids prenatally or antibiotics while giving birth were excluded, as were women whose babies passed meconium in utero, had congenital malformations, or required prolonged resuscitation after birth. Amniotic fluid was obtained by amniocentesis to determine fetal lung maturity prior to elective birth. Vernix was gently scraped from the newborn's skin with a sterile implement immediately following birth. The researchers obtained 10 samples of amniotic fluid and 25 samples of vernix.

Tests (Western analysis and immunochemistry) revealed that lysozyme, lactoferrin, human neutrophil peptides 1–3, and secretory leukocyte protease inhibitor were present in the amniotic fluid samples and in organized granules embedded in the vernix samples. These immune substances were tested using antimicrobial growth inhibition assays and found to be effective in inhibiting the growth of common perinatal pathogens, including group B. Streptococcus, K. pneumoniae, L. monocytogenes, C. albicans, and E. coli.

The authors point out that the innate immune proteins found in vernix and amniotic fluid are similar to those found in breast milk. As the baby prepares for extrauterine life, pulmonary surfactant (a substance produced by the maturing fetal lungs) increases in the amniotic fluid, resulting in the detachment of vernix from the skin. The vernix mixes with the amniotic fluid and is swallowed by the growing fetus. Given the antimicrobial properties of this mixture, the authors conclude that there is “considerable functional and structural synergism between the prenatal biology of vernix caseosa and the postnatal biology of breast milk� (p. 2095). They also suggest that better understanding of these innate host defenses may prove useful in preventing and treating intrauterine infection.
 

Significance for Normal Birth

Routine artificial rupture of membranes increases the likelihood of intrauterine infection because it eliminates the physical barrier (the amniotic sac) between the baby and the mother's vaginal flora. This study suggests an additional mechanism for the prevention of infection when the membranes remain intact: A baby bathed in amniotic fluid benefits from antimicrobial proteins that are found in the fluid and in vernix caseosa.

The results of this study also call into question the routine use of some newborn procedures. Early bathing of the baby removes vernix, which contains antimicrobial proteins that are active against group B. streptococcus and E. coli. Delaying the bath and keeping the newborn together with his or her mother until breastfeeding is established may prevent some cases of devastating infections caused by these bacteria. The fact that preterm babies tend to have more vernix than babies born at or after 40 weeks might mean that healthy, stable preterm babies derive even greater benefit from staying with their mothers during the immediate newborn period.

Finally, this study illustrates how the normal physiology of pregnancy and fetal development is part of a continuum that extends beyond birth to the newborn period. The immunologic similarities between amniotic fluid, vernix, and breast milk provide further evidence that successful initiation of breastfeeding is a critical part of the process of normal birth.
 http:


Host defense proteins in vernix caseosa and amniotic fluid.
Akinbi HT, Narendran V, Pass AK, Markart P, Hoath SB.
Am J Obstet Gynecol. 2004 Dec;191(6):2090-6.

OBJECTIVE: This study was undertaken to define the spectrum, activity, and spatial distribution of antimicrobial peptides in vernix caseosa and amniotic fluid in the absence of clinical chorioamnionitis. STUDY DESIGN: Characterization of innate immune proteins in vernix and amniotic fluid obtained from pregnancies with gestational ages greater than 37 weeks by Western analysis, immunohistochemistry, and antimicrobial growth inhibition assay. RESULTS: Lysozyme, lactoferrin, human neutrophil peptides 1-3, and secretory leukocyte protease inhibitor were identified by Western analysis in vernix suspensions (n = 25) and amniotic fluid samples (n = 10). Three other important antimicrobial proteins, human beta defensin-2, lactoperoxidase, and LL-37 were not detected. Amniotic fluid and soluble extracts of vernix exhibited muramidase (lysozyme) activity, and there was selective efficacy in inhibiting growth of common perinatal pathogens. Antimicrobial peptides were concentrated in discrete, organized, acellular "granules" embedded in the vernix lipid matrix. CONCLUSION: In the absence of chorioamnionitis, vernix and amniotic fluid contain an organized pool of antimicrobial peptides with a defined spectrum of bioactivity against common bacterial and fungal pathogens.



AROM and Cord Prolapse



Rupture of Membranes Causes Cord Prolapse


I've only heard about this - never tried it myself. But people say you can simply move the baby's head into the pelvis by applying pressure on the baby's butt and/or fundus to move it into the pelvis and prevent cord prolapse as the waters are broken.

Another possibility is to get the woman into a hands & knees posture while breaking the waters so that any loose cord will "sink" towards the fundus. Then try to move the head into the pelvis and or wait for the cervix to shrink up around the head after the waters are out before getting the mom back into an upright position.

These are the things that homebirth midwives talk about to prevent prolapse when they break waters with a high head, as a last resort, of course.



AROM and PIH



Does it make any sense that AROM would lower the mom's blood pressure or otherwise reduce risks of PIH?


Absolutely none I can think of.


NO IT DOES NOT>>>UNLESS YOU LIKE THE LOW BP OF SEPSIS!


unable to see what mechanism would be operant here. I've never heard this one.


I agree with you and I can only say that I have observed that the BP does go down.  What the action is-- and why it happens and if it really happens is unproven.  Just more of that old midwifery folklore.


I have seen many moms with PIH lower their BP once they go into labor, and others get higher. I can't see how AROM would have a direct affect on the PIH other than by inducing labor.


I think the goal of AROM in a PIH woman is simply to deliver her, thereby reducing the potential effects of PIH if the woman stays pregnant.  However, I have heard a couple of midwives' views that if a woman has elevated BP, THEY believe that AROM might not only cause her to deliver, but it also reduces, in their opinions, the extra fluid "pressure" on her body which can lower the BP. I have no experience in this, but AROM is usually the last thing I would want to do in a homebirth situation.


This is purely anecdotal, but my BP skyrocketed AFTER my water broke with my last baby - Water broke on her due date -- my cervix was completely unripe--hard, high (-5), closed.  In the 2 days after my water broke and before I was induced it got to 170/120.  Labor went really fast with induction, though!



AROM Technique



I love the MemCot: It's like a finger cot, with a firm plastic disc on the fingertip that has a pointy plastic bristle.  Much less intimidating to the mom than using a long pointed device such as the Amni-Hook.  I got mine from Cascade - item # 5696.

 




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